Shared care plans
Shared Care Planning is a cross-sector programme that works across all primary health organisations (PHOs), secondary care, and community care in Te Waipounamu South Island. Hosted by Pegasus Health.
Is a shared care plan right for me?
If you have one or more chronic health conditions, complex medical needs, long term disability, mental health concerns or need support from various services to support you to live well, then having a care plan may be of benefit to you.
Ask your health care team (general practice, community service providers or hospital providers) if a shared care plan would be a good addition to your health care planning and decide together which plan suits your needs.
For more information, visit Care planning and care plans (healthify.nz) or talk to your general practice team.
Acute plan
If you're often accessing hospital or after hours care because you have a chronic and/or complex health need, then an Acute Plan may be right for you.
The Acute Plan is a way of sharing important information about your health with other health professionals, so they know more about how to help you. This plan will help guide them with their decision making about your care needs.
It is created and updated by you and your health care team.
Personalised care plan
If you have chronic and/or complex health needs, a Personalised Care Plan (PCP) can help you write down your goals to achieve better hauora - health and wellbeing, and the actions needed to achieve these goals.
The plan supports you and your health care team to work together to achieve your goals, these can be big or small. The goals need to be clear, achievable and important to you.
It is created and updated by you and your health care team.
Health Professionals
Is a Shared Care Plan right for your patient?
If you have a patient who has a complex health condition(s) and has a high risk of presenting to acute services within a 12-month period, you may wish to consider completing an Acute Plan or a Personalised Care Plan (PCP) with them. These shared care plans provide a place to document important information which is relevant to the person’s health condition.
As the plans are accessed via Health Connect South / HealthOne, they can be shared amongst health professionals across Te Waipounamu, who are involved in the person’s care.
Acute Plan
Acute plans are designed to assist clinical teams who see people during acute exacerbations of complex health conditions.
The aim of the plan is to support safe, effective, person-centered decision-making regarding assessment, management and discharge.
Acute plan creation should be considered for any person who meets the funding criteria with a complex health condition(s), who has a high risk of presenting to acute services within a 12 month period. The plans can be updated as the person’s needs, or situation changes.
Personalised Care Plan
The plan aims to encourage people to work with their care team to plan care around their needs and priorities. When entered on Health Connect South, the PCP enables the person’s goals and actions to be visible to other clinical teams.
Auditing of the plans
Funding to create or amend the Acute Plan and Personalised Care Plans is available across all Waitaha Canterbury general practices. To ensure the funding is used equitably across all practices, plans are audited to ensure the funding criteria is met. If criteria is not met the releasing of the funds, for that plan, will be put on hold and your practice will be informed what plans do not meet criteria. Once this is corrected funding will be released.
